Neurosurgery
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This video illustrates access to tortuous distal intracranial vasculature and the use of intra-arterial (IA) tissue plasminogen activator (tPA) for the revascularization of small vessel occlusion. IA tPA is a reasonable approach for distal arterial occlusion resistant to intravenous tPA or mechanical thrombectomy. In this video, the patient had a posterior circulation stroke with elevated time-to-peak in the cerebellar hemispheres. ⋯ For occlusion of small intracranial vessels where IV tPA is ineffective and mechanical thrombectomy is unsafe, local administration of IA tPA can be an effective therapy. Consent was obtained from the patient prior to performing the procedure. Institutional review board approval is not required for the report of a single case.
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Acute ischemic stroke (AIS) and its care is currently one of the most dynamic and evolving illnesses across the globe. Among the most crucial factors in providing the best care to patients are the expedient delivery of thrombolytics and endovascular intervention when indicated. ⋯ The Neuro ED acts as our hub for EMS communication, imaging, administration of intravenous alteplase, and transition to the Neurointerventional OR. Our structure with its enabling of shortened IV alteplase delivery times and faster door-to-needle (DTN) times may serve as an international model for stroke centers.
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Hemodynamic factors, especially wall shear stress (WSS), are generally thought to play an important role in intracranial aneurysm (IA) formation. IAs frequently occur at bifurcation apices, where the vessels are exposed to the impact of WSS. ⋯ The magnitude of WSS strongly correlated with bifurcation geometry. In addition to high WSS, AREA and $| {{{\vec{F}}_w}} |$ were thought to affect IA formation. Observed bifurcation geometry may predict IA formation. Large branch angles and small branch may increase the risk of IA formation.
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The optimal management of unruptured brain arteriovenous malformations (AVMs) is controversial after the ARUBA trial. ⋯ The ARUBA trial conclusion that medical management is superior to medical management with interventional therapy for all unruptured AVMs could be repudiated.
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We present the case of a 68-yr-old woman who presented with an acute left middle cerebral artery syndrome. Noninvasive angiography obtained 13 h after last known well time demonstrated both left M1-segment middle cerebral artery (MCA) occlusion and near-complete occlusion of the left internal carotid artery (ICA) just distal to the carotid bifurcation. Intervention was offered given the sizeable mismatch demonstrated by computed tomography (CT) perfusion imaging. ⋯ Postprocedural imaging demonstrated preservation of the at-risk brain parenchyma. The patient demonstrated significant improvement in strength and speech after the procedure, and she was discharged to an inpatient rehabilitation center for further treatment. The patient and her family gave consent for this report.